Basic Information
| Provider Information | |||||||||
| NPI: | 1508893850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIBBY | ||||||||
| FirstName: | TAMARA-KAY | ||||||||
| MiddleName: | ALEXIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7728 PALM RIVER RD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336194215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136303637 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 302 W FLETCHER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336123415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138660930 | ||||||||
| FaxNumber: | 8134053722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DN15880 | FL | N | Dental Providers | Dentist | Pediatric Dentistry | 1223G0001X | DN15880 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 075270300 | 05 | FL | MEDICAID |